Did Beethoven have an irregular heartbeat? Medical historians look to his music for diagnostic clues

Ludwig van Beethoven’s deafness is well documented, but his other medical problems, including the illness that led to the great composer’s death in 1827 at age 56, are widely speculated on and debated by medical historians and physicians.

Reading the long list of illnesses that have been proposed as the cause of Beethoven’s death, which include cirrhosis of the liver, syphilis, lead poisoning, diabetic kidney disease and Paget’s disease, I’m reminded of the parable of the blind men and the elephant: A group of blind men encounter an elephant for the first time. Each gropes a different part of the animal to try to make sense of it. One places his hands on the elephant’s trunk, while another grabs its leg, a third its tusk, and so on.  Each man then immediately forms an opinion of what they are touching. “A thick snake!” “A tall tree!” “A large spear!” 

In some versions of the parable, a huge fight breaks out among the men.

I sometimes think that physicians tend to see in the lives and deaths of historical figures the signs of disease — the part of the elephant, if you will — with which they are most familiar.

Of course, that doesn’t mean that their diagnoses of historical figures are necessary wrong. 

Diagnosing Beethoven

All of this is a rather long-winded way of issuing a caveat before I introduce an interesting, but highly speculative, historical diagnosis about Beethoven’s health that was featured in a 2014 essay in the journal Perspectives in Biology and Medicine. The essay, which I stumbled upon earlier this year while doing background research for another Second Opinion post, proposes that Beethoven had cardiac arrhythmia, an irregular heartbeat.  

Furthermore, say the essay’s authors — a cardiologist, a medical historian and a Beethoven scholar — the evidence of Beethoven’s heart arrhythmia can be found in some of his music.

I was surprised to learn that this isn’t a new theory. It’s been around for decades. In a letter published in the Journal of the American Medical Association (JAMA) in 1980, Dr. Samuel Vaisrub, a physician and JAMA editor, suggested that Beethoven’s arrhythmia can be detected in his compositions, specifically in the “disordered rhythm” of his Piano Sonata in E-flat Major (Opus 81a), which was written in Vienna in 1809.  

The authors of the 2015 essay go beyond Opus 81a, however. They claim that two later compositions — the fifth movement (“Cavatina”) of the String Quartet in B-flat major (Opus 130) and the Piano Sonata in A-flat major (Opus 110) — may also be “musical electrocardiograms.”

‘Heavy of heart’

The “Cavantina” movement is “an emotionally-charged piece that Beethoven said always made him weep,” explains Dr. Zachary Goldberger, the paper’s lead author and a cardiologist at the University of Washington, in an article about his research for The Conversation. “In the middle of the quartet, the key suddenly changes to a C-flat major, involving an unbalanced rhythm that evokes dark emotion, disorientation and what has been described as a ‘shortness of breath.’” 

Shortness of breath is a symptom of heart arrhythmia.

Goldberger and his co-authors provide more details in their Perspectives essay: 

The syncopated melody combines with triplets in the accompaniments. This section is marked beklemmt, a German word that can be translated as “heavy of heart.” But the German word also carries other connotations: in addition to a sensation of heaviness, it also evokes the sensation of being “pinched” or “squeezed.” Pianist Jonathan Biss, in a recent publication, says that this section evokes for him a sensation of shortness of breath, which he associates with intense emotion, but which could also be associated with cardiac arrhythmias. This section of the quartet lasts only seven measures and ends with a pause, before the original theme returns. The sensation of the chest being “squeezed,” possibly associated with shortness of breath, quickly brings to mind the possibility of ischemic heart disease. Such ischemia could be either the cause or the result of an arrhythmia. 

The researchers find similar symptoms in the Piano Sonata in A-flat Major, which Beethoven was unable to complete on schedule, in part because of illness:

The finale of Opus 110 has a quite unusual structure: it contains two fugues, each preceded by an ‘ariosos dolente’ (lamenting song). The second arioso has an asymmetrical melody in concert with repeated chords in the bass. The ostinato, repetitive quality of the left hand bears some resemblance to rapid tachyarrhythmia, often associated with chest heaviness and palpitations. The melody played in the right hand sounds like a vocal line being sung, but as though the singer is feeling dyspneic, gasping for air and able to get out only a syllable or two with each breath. This would not be an unusual sensation for someone experiencing a tachyarrhythmia.

“Beethoven would have been keenly aware of this heart’s rhythm,” Goldberger and his co-authors add. “One can usually become aware of one’s heartbeat simply by resting quietly, and surely there is no quieter existence than being completely deaf,” they write. “The gradual diminution of one sense, hearing, probably left Beethoven’s other senses more acute, and his deafness may very well have left him even more aware of the beating of his heart.”

Literally ‘heartfelt’

When Beethoven’s body was autopsied, doctors found no structural problems with his heart, although, as Goldberger and his co-authors note, “many of the tools we now use to examine the heart at autopsy were not available in the early 19^thcentury.”  

The three men also point out that heart disease in the form of cardiac arrhythmia would not be visible to the naked eye during an autopsy. 

Yet, if Beethoven’s medical symptoms were presented to a doctor today, he or she would probably suspect the presence of heart disease, they insist. 

So, is this historical diagnosis another example of the blind men in the parable — people interpreting something through their own specialized experiences?

Goldberger and his co-authors acknowledge that diagnosing Beethoven’s medical problems through his music is fraught with problems — and is, in the end, just a hypothesis.

“We recognize that the musical ‘arrhythmia’ may simply manifest Beethoven’s genius as a composer, and that similar rhythmic intricacies may be identified in other works by many composers,” they write. “However, in highly charged passages of certain pieces, the possibility of cardiac arrhythmia can lend a quite physical aspect to one’s interpretation of the music in question. These passages can seem, in an unexpectedly literal sense, to be heartfelt.”

For more information:You’ll find an abstract of the paper on the Perspectives in Biology and Medicine website, but the full paper is behind a paywall. You can, however, read Goldberger’s account of the research at The Conversation. You can also test out the cardiologist’s theory about Beethoven’s “heartfelt” music yourself at the Minnesota Beethoven Festival, which runs July 2-22 at various venues in Winona.